Doctors in the operating suite, post-operative cognitive dysfunction

When you are told you need surgery, there is a lot to think about. What kind of surgery, and what is the recovery like? Will you need to spend time in the hospital? You need to know the risks and benefits of the procedure to make a decision. However, many people don’t consider the anesthesia. How likely are you to suffer post-operative cognitive dysfunction from the anesthetic?

Does Anesthesia Cause Cognitive Difficulties?

Q. Recently, two family members underwent surgery. Although the surgeries were different, the family members experienced similar unexpected complications upon awakening. They suffered hallucinations, memory impairment and cognitive difficulties after anesthesia.

I did some independent research and found that this can happen. Sometimes the memory is regained and the person completely recovers. Other times the person never completely regains full cognitive function. Are some anesthesia drugs more prone to cause this than others?

What Is Post-Operative Cognitive Dysfunction?

A. Doctors have an acronym for this condition: POCD (post-operative cognitive dysfunction). It is most common in the days and weeks immediately following surgery, but even months later some people have measurable cognitive decline (Kotekar et al, Clinical Interventions in Aging, Nov. 8, 2018). 

Propofol May Be Better:

It can be difficult to compare different anesthesia protocols. However, a recent prospective randomized controlled trial of 164 patients found that propofol was less likely to cause post-operative cognitive dysfunction than either midazolam or dexmedetomidine (Li et al, China Medical Journal, Jan. 30, 2019).  A review of the available research compared intravenous propofol to inhaled anesthetics (Miller et al, Cochrane Database of Systematic Reviews, Aug. 21, 2018).  The authors bemoaned the lack of high-quality research. Nevertheless, they concluded that propofol may offer an advantage for reducing POCD. They point to 11 trials currently underway, with hopes that they will provide better data on this important question.

Readers Weigh In:

We have heard from some readers who conclude on the basis of their experience that propofol is less likely to lead to post-operative cognitive dysfunction. Here is one example.

Q. After reading your column on the aftereffects of anesthesia, I want to share my own experience.

I had severe memory lapses for months after undergoing anesthesia. It was like knowing something was in a filing cabinet, but not being able to see what is in the folder. It is frustrating to know the information is there, but you can’t access it.

Thankfully, my brain function did return to normal, but it took months. My physician suggested propofol for future surgeries. I have needed anesthesia a few more times over the last several years and have not experienced aftereffects again.

A. Post-operative cognitive decline is surprisingly common, though the cause remains controversial. Propofol is an injectable anesthetic. One study showed less impairment among patients getting propofol compared to those getting the inhaled anesthetic sevoflurane (Hussain et al, Clinical Interventions in Aging, online Sept. 24, 2014).

It makes sense to ask the surgeon ahead of time if a peripheral nerve block would be appropriate. In some cases, such as knee surgery, that may be another option (Liu et al, Clinical Interventions in Aging, online Feb. 18, 2014).

People who find that they are spacey or forgetful after surgery should be patient with themselves. In most cases, the cognitive problems (which may also be linked to insomnia) will disappear over time.

Does the Doctor Use a Brain Monitor?

We heard from Barry in Corona del Mar, CA:

“Anesthesia providers can only guess how much anesthetic you might need. Without a brain monitor, one American patient dies every day from anesthesia over medication. Prior to 1996, to insure an adequate experience, we tend to err on the side of too much. Since the FDA approval of the BIS brain monitor, it is now not only possible but also highly desirable to directly measure individual response to avoid brain fog (aka post-operative cognitive dysfunction or POCD). Watch You Tube Going under with Goldilocks anesthesia. Learn what you need to know by reading ‘Getting Over Going Under.’ Complimentary copies from drfriedberg@drfriedberg.com. DISCLAIMER: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from makers of the BIS monitor.”

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  1. Chaela
    Denver
    Reply

    Was married to anesthesia medical researcher. He said simply “do not undergo general anesthesia unless you have no other choice. Local is best, shortest acting is best.” I have had four surgeries in past 15 years using his advice. AOK. The less meds for the shortest time periods the better.

  2. Sally
    USA
    Reply

    My husband had two major surgeries resulting in what we were told was “ICU Psychosis”. The last surgery where a 2-day stay was expected (hernia repair), resulted in a 1 month ICU stay. I was told that he was probably in dementia prior, but no. He wasn’t to my knowledge! I was also told that he may never recover. His own experiences were terrifying to him, and he still has hallucinatory flashbacks. His memory has not fully recovered, but is OK, and he is fully functional. These 2 experiences have scared us to death about any idea of future surgeries.

  3. James
    SC
    Reply

    Where is Barry’s source from? He is saying “Without a brain monitor, one American patient dies every day from anesthesia over medication.”
    I would like to see posts reflect their sources. Here is mine:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697561/
    “Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005
    Conclusion:
    Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.
    The results of our study suggest that the United States has experienced a 97% decrease in anesthesia-related death rates since the late 1940s and the mortality risk from complications and adverse events of anesthesia/anesthetics for surgical inpatients is similar to the reports from other countries, at about 1 in 100,000. Our study found that 42.5% of anesthesia-related deaths were attributable to adverse effects of anesthetics in therapeutic use. With the increased use of anesthesia outside of the traditional operating room setting,21,22 continued monitoring of the safety of anesthesia is warranted.”

    34+281=315, that is not even 365 (a whole year).

  4. Susan
    Winston Salem
    Reply

    I have had problems with Versed. I have never had problems with Propofal. I made sure that I was given Profofal during my last colonoscopy. I need a colon resection because of diverticular scarring. With what’s going on in corporate medicine right now, I’m terrified enough. Fear of anesthesia is another thing added to my list.

  5. michael
    carolina
    Reply

    In the late 70’s or early 80’s the AMA was trying to get acupuncture banned in the USA. Quackery!
    frontline on pbs went to China, and I watched a man have open heart surgery with his chest cracked open, heart beating, while he chatted with the reporter.

  6. Kristin
    WI
    Reply

    This article is EXACTLY RIGHT. I had severe memory loss for several months after knee replacement surgery when I was give the anesthetic Versed. My memory was so bad that even though I’d made a chart so I could remember when to take my meds, if I took a pill first, I would forget to write it down. If I wrote it down first, I forgot to take the pill. I never knew what I took or when, but luckily I survived even though I was living alone and had no help.

    For several months following the surgery I could not remember even 4 numbers, even if I repeated them until I got a pencil to write them down. I felt like I had dementia and was embarrassed at all the things I forgot. For several days after the surgery, I asked friends to call me every 4 hours to be sure I was ok. But I forgot that they were going to call and was gone at the time of the call. My friend called the sheriff, and they were out looking for me when I got back. That “friend” refused to believe that I was having memory problems and never spoke to me again. A year later I had my second knee replaced and requested a different anesthetic. They gave me Propofol, and I had no memory or other problems at all. I now have it on my permanent medical record that I am allergic to Versed (I threw up at least 7 times the night following the surgery).

  7. JP
    web
    Reply

    I’ve had propofol for my last surgery some years ago and for a recent EGD. Both times I suffered a reaction from it, horrible mucosal dryness so severe I had to stay longer in the hospital while IVs were on super-drips to try and flush it out of my system. NEVER AGAIN!

  8. laura baker
    GA
    Reply

    I am SO GLAD to see this article. I have had surgeries decades ago, but nothing for 30 yrs, until my cataract surgery, where I was given propofol/fentanyl for only 5 minutes!! That was over a year ago, and I still have symptoms. My symptoms are “hunting for words”, slow reactions in conversations, not severe, but obvious to me. I also got a very bad cold the next day and for the next week. I am afraid to have any more of these drugs; and am glad to have the suggestion to ask for a nerve block if appropriate.

  9. Ellen Childress
    Dallas, Texas
    Reply

    My husband had two stents placed a year ago. For several weeks after that, his speech was garbled and an existing memory problem got worse. Gradually, his speech has cleared
    and the memory issue is no worse than before. But when I was given propofol three times in three days related to gallbladder surgery four years ago, I lost my senses of smell and taste and have not regained them at all.

  10. Phil
    MO
    Reply

    Duke University did research some years ago on cognitive decline after surgery involving anesthesia and found that the greatest impact was on patients age 65 plus. I can certainly attest that at age 78 I had notable permanent cognitive impairment after cardiac artery bypass surgery. I should note that my surgery extended over a period of more than eight hours due to complications.
    The cognitive impairment I have is somewhat difficult to describe. It seems my brain is working OK, but when I attempt to vocally articulate what I am thinking, the words get scrambled and I am able to call up just a fraction of my vocabulary. When professionally active, I was a university professor who taught undergraduate and graduate courses and gave many professional seminars and presentations. Today, I would be unable to perform those tasks without sounding slow, backward and inarticulate. I wish I did not have these difficulties…but I am very much alive and enjoying life. What is interesting to me is that my writing skills have been seemingly unaffected!

  11. Penelope
    FLorida
    Reply

    Post Operative cognitive impairment is probably even more pronounced for the elderly. My 90- year old neighbor had repeated falls and breaks requiring surgery with anesthesia. Each time he progressed more steadily down the path of Alzheimers. I’ll remember this in the future! I’ve never said this before despite the comments.

  12. Penelope
    FLorida
    Reply

    Post Operative cognitive impairment is probably even more pronounced for the elderly. My 90- year old neighbor had repeated falls and breaks requiring surgery with anesthesia. Each time he progressed more steadily down the path of Alsheimers. I’ll remember this in the future!

  13. Carla
    Fountain NC
    Reply

    In 2005 following total knee replacement at age 55, I was totally confused and not aware of my surroundings for about 5 days, followed by total loss of memory of events about 9 months prior to surgery. I still have ongoing memory loss after having above-normal memory prior to 2005. No one ever related it to the anesthesia, and connected it to a seizure disorder, controlled. However, I began questioning the anesthesia. When I needed to have the left knee replaced in 2015, I had changed surgeons and hospitals due to a move. When I discussed my thoughts about it to both the surgeon and neurologist, they totally agreed, and made adjustments to the anesthesia (I do not know what change was made). Post-surgery memory loss was present, but no where near that of the 2005. It is so good to read this article and the connecting journal research articles – I felt as though it was a predictor of dementia or Alzheimer Disease.

  14. deborah
    angel fire, nm
    Reply

    Interesting reading this find. I had general anesthesia back in 2003, prior to this I was very active with art but after coming out I have not regained that creativity and memory is not as sharp.
    Never do I wish to go through that again, however I had a root canal, an extraction of a tooth and a colonoscopy with Propofal and no problems at all. None.

  15. Marilynn
    NE Illinois
    Reply

    I didn’t have POCD. I had terribly violent nausea and vomiting. No amount of pills or shots would lower it. After my hysterectomy, it took 2 weeks to get over it. By then, my chest muscles were so sore, I cried with every retch.

    And my allergist said to find out what it was, as another time could kill me. BUT, they refused to tell me!

    My retinal surgeon took that into account, and used something else, but refuses to tell me what did NOT make me ill.

    So now I refuse to ever have surgery again, for fear of what happened the first time. I cannot go thru that again.

    PS My cataract removal Dr. used Versed, which made me very ill too, but not quite as bad as the first instance.

  16. Bill
    Alabama
    Reply

    Friends of mine , husband and wife have both had several procedures requiring anesthesia. Both have had seizures occurring some few months after these procedures which were successful. The husband also had and continues to have memory problems three years after the procedures. Neither one had ever had seizures before. The wife, however, has not had memory problems, but she was the first of the two to have seizures. Both continue on medication to control these seizures. They were both in their early seventies when this began. Are seizures part of the after effects of anesthesia ?

  17. Francine
    Reply

    I have had severe adverse reactions to anesthesia, to the point where I refuse to have surgery, unless it can be done under local or regional anesthesia. This is my understanding after extensive research and talking to a knowledgeable anesthesialogist. Apparently most of the damage happens from the volatile gasses and pre-meds they give. Any time you have general anesthesia where you have to have a breathing tube, there is a higher risk. If you have had any type of brain injury previously like a concussion or TBI or are sensitive to drugs your risk of an acquired brain injury from anesthesia goes way up, and can cause permanent cognitive damage to the brain.

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